Painless bilateral eyelid edema with foamy urine

Specialty: Pediatrics.

• Children's facial swelling
• pediatric renal edema
• suspected nephrotic syndrome

Why it occurs

• Minimal change nephrotic syndrome or SNCM (the most common primary glomerulopathy in pediatrics, characterized by a massive loss of protein by the kidney due to the fusion of podocytes, typical between 2 and 6 years of age)
• Acute post-streptococcal glomerulonephritis (nephritic syndrome secondary to a previous pharyngeal or skin infection by Streptococcus pyogenes, which associates edema, hematuria, hypertension and oliguria)
• Nephrotic syndrome secondary to systemic diseases (Systemic Lupus Erythematosus, Henoch-Schönlein Purpura with kidney involvement)
• Systemic allergic reaction or angioedema (although it usually appears suddenly, is pruritic and does not associate urinary alterations)
• Congestive heart failure or chronic liver disease with severe hypoalbuminemia (rare causes in children with no known history).

Initial workup

Systematic urine and sediment examination (to quantify proteinuria using a dipstick, typically 3+ to 4+ in nephrotic syndrome, and look for micro- or macrohematuria). Quantification of protein in 24-hour urine or determination of the protein/creatinine ratio in an isolated urine sample (nephrotic range proteinuria values: > 40 mg/m2/hour or proteinuria/creatinuria ratio > 2 mg/mg). Complete blood analysis: total proteins and albumin (typically hypoalbuminemia < 2.5 g/dl), lipid profile (reactive hypercholesterolemia and hypertriglyceridemia), renal function (urea, creatinine), serum electrolytes, complement levels C3 and C4 (typically normal in SNCM and decreased in post-streptococcal glomerulonephritis).

Standard management

• Prednisone or Prednisolone — first choice corticosteroid for the treatment of minimal change nephrotic syndrome, highly responsive in children; induction dose of 60 mg/m2/day or 2 mg/kg/day orally, maximum 60 mg/day, administered for 4 to 6 consecutive weeks, followed by a tapering schedule every other day for several weeks under close medical supervision
• Furosemide — loop diuretic indicated for the management of refractory edema or severe volume overload; doses of 1 to 2 mg/kg/day orally or intravenously, closely monitoring potassium and blood volume status to avoid thrombosis
• Calcium and Vitamin D3 supplements (for the prevention of osteopenia secondary to prolonged corticosteroid therapy).